1568575777 NPI number — KIMBERLY TYNER MD, PA

Table of content: (NPI 1568575777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568575777 NPI number — KIMBERLY TYNER MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLY TYNER MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568575777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 S CLAY ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
ENNIS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75119-5771
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-878-9400
Provider Business Mailing Address Fax Number:
972-878-9403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S CLAY ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
ENNIS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75119-5771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-878-9400
Provider Business Practice Location Address Fax Number:
972-878-9403
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TYNER
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-878-9400

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00451V . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com